Inclusa has selected WPS Health Insurance to process all claims transactions. Any claim that is submitted to WPS must be received within 90 days of date of service and accepted as a clean claim. WPS will reject all claims that do not include the elements of a clean claim or are not filed within the required timelines. Clean paper claims which are filed timely to WPS will generally be processed within 7-10 business days of receipt. Clean claims filed on an Excel Spreadsheet (for applicable providers) are generally processed within 2-5 business days of receipt.
- Clean Claim: a complete and accurate claim that includes all provider and member information necessary to process the claim including all appropriate service and authorization codes.
- Filed Timely: claims must be filed within 90 calendar days from the date of service. The claim filing timeline does not end with the original claim submission. If a claim is rejected or denied back to the provider, the provider must submit a corrected claim within the original 90 calendar days from the date of service.
- Business Days: any day including Monday to Friday; does not include weekends or holidays.
All payments and/or denials are accompanied by an Explanation of Benefits (EOB) or rejection notice, which gives the specific explanation of the payment amount or specific reason for the payment denial. Any inquiry regarding the rejection/denial should be directed to WPS Call Center Monday through Friday between 8:00 AM and 4:30 PM at 1-800-223-6016.
If you dispute this initial decision, you may appeal by submitting a separate letter, within 60 calendar days of the initial denial or partial payment using one of the following methods:
Mail: Inclusa, Inc.; 2615 East Avenue South; Suite 103; La Crosse, WI 54601
The letter must clearly be marked as “Formal Appeal”. It must contain the provider’s name, member’s name, service code (billing code), date of service, date of rejection, reason(s) claim merits reconsideration, and any supporting documentation. Each member must be on their own letter.
If Inclusa fails to provide a written response within 45 calendar days of the date of receipt of the appeal, or you are dissatisfied with Inclusa’s response to your request for reconsideration, you may appeal to the Department of Health Services (DHS). This appeal must be submitted in writing within 60 calendar days of Inclusa’s final decision using one of the following methods:
Fax: (608) 266-5629
Mail: Provider Appeals Investigator/Division of Medicaid Services
1 West Wilson Street, Room 518
PO Box 309
Madison, WI 53701-0309
DHS will solicit written comments from all parties to the dispute prior to making the decision. DHS has 45 calendar days from date of receipt of written comments to respond to this appeal. Providers must accept DHS’ determinations regarding appeals of disputed claims. Inclusa agrees to pay providers within 45 calendar days of receipt of a DHS final determination in favor of the provider.